Playing to good health

The Nintendo Wii has taken the country by storm and is being promoted as a healthier alternative to video game consoles that don’t require full-body participation.

Now, health leaders are exploring whether gaming has a place in healthcare, most notably in chronic care and in teaching children about healthy living.

Using games to improve health turns the negative perception of video games on its head. Until recently, parents and health advocates railed against the correlation between playing video games and lack of exercise.

However, with 70% of American heads of household and millions of children playing computer and video games, the gaming industry and healthcare system are considering gaming as a possible way to improve health.

“Games are not just looked at as evil media that hurt you. Now there is an appreciation that you can design games that are not harmful, but can be beneficial,” says Debra Lieberman, PhD, communication researcher at the University of Santa Barbara’s (CA) Institute for Social, Behavioral, and Economic Research.

Games do not simply teach; they also engage users. If a company creates a health-related video game that is boring, no one will want to play it, and the chance for engagement is lost.

One example of a health-related video game is HopeLab’s Re-Mission, which was developed for teens and young adults with cancer.

The game is a 20-level third-person shooter video game in which the players portray a nanobot named Roxxi. In that role, players shoot to kill cancer cells in the fictional cancer patients and defend against bacterial infections and side effects. A study of the game showed that users learned about cancer and adhered to their treatment regimens. In 2007, CIGNA began offering Re-Mission free to cancer patients who requested the game.

The Robert Wood Johnson Foundation understands the potential of gaming in health. Lieberman is heading the foundation’s national Health Games Research program, which supports research to enhance the quality and effectiveness of interactive games to improve health. The foundation plans to give $8.25 million to researchers looking at how games can improve health and healthcare.

In the first round of grants, the foundation gave $2 million to 12 teams that are researching games to help people with dietary behavior issues, glycemic control in diabetes, and chronic mobility and balance deficits after a stroke, as well as gauge the effectiveness of social mobile-network games in promoting active lifestyles for wellness. The foundation received 112 research proposals submitted by universities, medical centers, and game industry organizations.

The foundation plans to give another $2 million in grants in January 2009.

The researchers are not only exploring video games, but other types of technology as well, such as cell phones. “What’s kind of neat is you don’t have to create a console game that could cost millions of dollars to give people a really compelling experience,” Lieberman says.

The foundation also wants to strengthen the evidence base, investigate health game design principles, demonstrate effectiveness and improve future games, and set a standard for theory-based design.

In addition to grants, the foundation is helping game developers and health experts collaborate and share best practices.

Lieberman says a benefit to video games is the immediacy. The user instantly knows whether he or she has the correct answer to a problem.

“We’re in the early days in the arena of games for health, but I think there is a lot of potential there to shift the health education paradigm from the walls of a medical center or patient handouts to a real-time simulated environment,” says Trinton Histon, PhD, director of Kaiser Permanente’s (KP) Weight Management Initiative in Oakland, CA.

“Human beings are just playful creatures. As much as we can combine that play with something healthy … that is a wonderful, powerful concept,” says Carolina Barnes, executive producer and owner of Digital Dream Forge, a gaming company in Tucson, AZ, that helped develop KP’s The Incredible Adventures of the Amazing Food Detective.

Food Detective

Pint-sized Columbos are on the case. KP launched its The Incredible Adventures of the Amazing Food Detective on its Web site in September 2007. The game, geared to 9- and 10-year-olds, teaches children about nutrition and physical fitness.

Rather than rely strictly on educational pamphlets, KP decided to harness the Internet’s power and deliver the health message in a new way.

The game builds upon the work of KP’s Healthy Eating Active Living and Community Health Initiatives to provide broader outreach to children and families. Childhood obesity in the United States has tripled in the past 15 years. Nearly 9 million children are overweight or obese, and research shows that the vast majority of those children will grow up to be overweight or obese adults, which is a pathway to diabetes, coronary artery disease, hypertension, and several other chronic illnesses.

Histon says KP chose to focus on the 9- and 10-year-olds because those children are old enough to exercise authority over their lives. When creating the game, KP was inspired by its educational theater program, which conducts two- to three-hour school programs on healthy eating and physical activity issues.

One of the skits is “The Incredible Adventures of the Amazing Food Detective.” The actors take on different health or nutritional problems, such as not eating enough protein or not getting enough exercise, and the children help the detective solve the problem.

KP developed the game by bringing together health educators, pediatrics, and Digital Dream Forge representatives to determine how to translate the live performance to the online environment. The group developed characters that mirror children in KP’s service area and included fitness and nutritional problems facing youths.

Digital Dream Forge and KP used that information to create the game in eight months. The game includes a health mystery for each child. For example, Cole eats too much junk food, Catherine is not very strong, and Althea skips breakfast. The player then uses that information to help the character make better decisions.

Once successful, the player is given an opportunity to print educational game materials as well as play health-related minigames.

KP also collaborated with educational publisher and media company Scholastic in New York City to create a healthy living lesson plan for teachers and bring the game into schools. “They knew what would resonate with children, but they also knew what would resonate with teachers,” Histon says.

Scholastic distributed supplementary educational materials that meet national learning standards along with CDs of the game to more than 5,000 public schools. The materials included a teaching guide with lessons and activities, family fun pages that reinforce what is being taught in the classroom, and a poster with a monthlong list of healthy ideas for the classroom.

“It could be either used in conjunction with the game in the classroom or as an aside,” says Histon. “It really taught kids about the building blocks of good nutrition and the importance of physical activity and sort of dispelled some of the misconceptions about nutrition—what’s healthy and what’s not healthy.”

Histon says the collaboration of KP, Digital Dream Forge, and Scholastic was key, as the health plan benefited from the gaming and education experts. “I think it was the sort of collaboration between those three entities that made it work. We could have done it, but I honestly don’t think it would have had the same impact,” Histon says. “It’s important to identify good partners from the get-go and then be thoughtful and collaborative as you move along the partnership.”

The game’s developers also needed to address a potential paradox: How would they create an online game about fitness in which children sit in front of a computer screen to play?

“One of our challenges was that games are part of the problem,” says Barnes. “We had to be very careful. We wanted to create a game that kids would want to play. But, if it was successful, we would contribute to the problem.”

The solution? KP, which suggests a one- to twohour limit to online use per day for children (including homework), decided to add a shut-off feature to the game so children can only play it for 20 minutes at a time.

KP distributed the game to 5,000 schools in its service area in September 2007, but has allowed those outside of KP’s area to download the game. The game’s learning materials have been downloaded 30,000 times. “We have had a lot more outreach than we would have expected,” says Histon.

The game has even reached Spain, where teachers have asked Kaiser for permission to make the Spanish version part of their curriculum.

Histon says it’s too early to gauge the game’s effect, but teachers have told KP that children are more engaged and better understand the importance of nutrition. “They are also choosing healthier snacks in their lunchbox,” she says.

The game has been recognized by several organizations, including iParenting Media and Interactive Media.

Additionally, the game is less than one year old, but KP has already seen the benefits and is exploring future avenues in gaming.

“I think we’re at the beginning of our journey in terms of really understanding this whole space of games for health, but it’s been very clear to me that we need to adopt a new paradigm on how we deliver both the nutritional and physical activity for children and their families,” says Histon.